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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ft-1 9� <br /> OWNER OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME 61 :FNE A�V-G" LL C� <br /> SITE ADDRESS DIESS <br /> 50 Street Number DL ction n TA IN Rc;tGNaTma SJ GN g52C-)7- <br /> Stree2 Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) I, y��,/ � r� 1 <br /> ) sT / 7•- - 1 Street Number V" I AoV'TF- Str. m Jv G-7 <br /> CIT' 1 V C-\C\C \ 0Imo+ STATE ZIP (] C L o� <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# _1.J <br /> (") 3I 5 �lU gZ <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work"e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard , FEDERAL laws. <br /> APPLICANTS SIGNATURE: DATE: 06 12 06 r Z <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> 1f APPLICANT is not fhe BILLLVG PARTY proof of authorization to sign is required rille <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> Information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and yelit is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: /IZ tAJ 6Q. <br /> COMMENTS: <br /> SAN JOAQUIN COUNT' <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: �f�tiC EMPLOYEE#: DAtEf 2-& - 1 ' <br /> ASSIGNED TO: G•� v U EMPLOYEE M DATE: -; <br /> 2 <br /> d <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: I 2 <br /> Fee Amount: ��Zle9 Amount Paid l S Z _ Payment Date �2 <br /> Payment Type vv ' Invoice# Check# ` � Received By: <br /> L <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> e P-o u'SUU <br />